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Equity based approach to
accelerate MDG 4 and 5 in
Pakistan
13 April 2011- Islamabad
Conventional wisdom holds that
equity in inefficient:
Too costly
Too difficult to go into poor, hard to reach
communities;
reaching better off, easier to reach
children has been considered more cost
effective…… the Current Path
UNICEF
Tackling
poverty
Coverage frontiers: shifting
production of health
Climb
Shift
Achieve better
service coverage
Health
With better
services
Join
Plan
Poverty
NEW EVIDENCE CHALLENGES CONVENTIONAL
WISDOM
1. Causes of mortality in deprived groups vulnerable to
evidence based high impact interventions
2. Estimated Intervention impacts can be quantified
3. Burdens disproportionally concentrated in deprived
groups in insufficiently reached
4. Bottlenecks:
1. poor availability,
2. geographical, financial and socio-cultural access,
3. continuity and quality
5. Innovative strategies with evidence based effect
sizes
6. Additional cost can be compared to impact estimates
to compare cost-effectiveness
Under five mortality causes in
Pakistan
120
100
Others
Injuries
80
AIDS
60
Pneumonia
Measles
40
Malaria
20
Diarrhea
-
Neonatal
Most Deprived
least Deprived
Source PDHS 2006-07, modeled by LSHPH (Simon Cousins) and JHU (Hope Johnson) based
on CHERG data
Neonatal mortality causes in Pakistan
50
40
Other
30
Diarrhea
Congenital
20
Tetanus
Severe infection
Prematurity
10
Asphyxia
0
Most Deprived
least Deprived
Source PDHS 2006-07, modeled by LSHPH (Simon Cousins) and JHU (Hope Johnson) based
on CHERG data
Multiple cost effective
interventions to reduce
mortality and
malnutrition
60
Increasing inequality
Unequal
progress
Countries with declining
under-five mortality and
increasing inequality in
under-five mortality
between the poorest and
the richest
50
40
30
Pakistan
20
Bangladesh
10
18/26 countries that
have made progress
have worse inequalities
-70
Declining inequality
Increasing inequities: in
many settings, the
manner of delivery and
financing favor the better
off
Nepa
l
-50
-30
0
-10
10
30
50
-10
India
-20
-30
Countries with declining
under-five mortality and
declining inequality in
under-five mortality
between the poorest and
the richest
-40
-50
-60
Declining underfive mortality
Increasing under-five
mortality
UNICEF PFR 2010
70
Equity profile of 7 key indicators in
Pakistan
100%
90%
Percent not stunted
80%
Primary net attendance rate
70%
60%
DPT 3 immunization
coverage
50%
Skilled attendant at delivery
40%
Comprehensive knowledge
of HIV (women aged 15-24)
30%
20%
Use of improved sanitation
facility
10%
Birth registration
0%
Lowest
Second
Middle
Fourth
Highest
90%
Pattern of inequity:
Child Deprivation Score
Bangladesh
80%
70%
India
60%
Nepal
50%
40%
Pakistan
30%
20%
UNICEF
Poorest Second Middle Fourth Richest
Testing these interactions in different contexts
• Reviewed effective large scale programmes
• Devised an equity-focused approach building on
the literature and Alma Ata Declaration(1978)
• Designed an analytical framework for modeling
• Undertook modeling exercise
- used data from 15 out of 60 countries reviewed
- analyzed 180,000 data points
- modeled expected impacts on MDG’s, costs and
cost-effectiveness of ensuring universal access to
proven high impact intervention package through
evidence based equity focused strategies in most,
medium and least deprived areas of 15 countries
Equity Analysis approach
• Basic model of “bottleneck framework”
• Target groups prioritised: most deprived,
• outputs for most deprived Current Vs
Equity focused
• additional cost and impact for reaching
disperse and remote areas
WHY?: Analyzing Bottlenecks
35%
30%
25%
To
Coverage
20%
15%
10%
From
inputs 35
5%
30
25
20
15
10
5
0
5% 10% 15% 20% 25% 30% 35%
10
102
Barriers
to increased
10
effective
coverage are
10
identified
by examining the
10
10
bottlenecks
to increasing
10
coverage
levels for the existing
level of inputs
3
4
5
6
7
Core concept: Identification of Bottlenecks
demand vs supply
Impact
Effective coverage- quality
Adequate coverage- continuity
DEMAND
Utilisation – 1rst contact with services
Accessibility – physical access to services
Accessibility – to human ressources
SUPPLY
Availability – cri tical inputs to Heath system
UNICEF
Target Population
From Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)
http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf
Tanahashi
Model
Health System
building blocks
Impact
Effective Coverage
Adequate coverage
Initial Utilization
Geographic Access
Human Resource availability
Availability of commodities
Target Population
Technology
Service Quality
HMIS DHIS (registers)
DHS , MICS (surveys)
Financial Access + IEC
Infrastructure
Human Resources
Drugs & Supplies
HMIS (epidemiology)
Bottlenecks within the continuum of care can have a
cumulative affect
Girls Education, Out of
School
Antenatal
care
Most deprived
pregnant women do
not utilize ANC
services
Childbirth care
Women will not opt
for skilled birth
attendance
Postnatal
and
newborn
care
Women will not bring
their newborns for
post- natal visit.
Newborn will not be
breastfed. No “skin to
Endangers
skin” contact
Subsequent accumulation of
a
Handwashing
Lack of human resources
Those
who opt for
cascade
of SBA
bottlenecks
or lack of quality
of care
might find poor
Lack of awareness of
danger signs/ feeding
practices
quality services, lack
of support in initial
breastfeeding
ECD
Mother’s
and
IYCF, Birth
Newborn’s
registration,
Immunization,
lives
…Birth Spacing
Most common Bottlenecks of Key
interventions for most deprived
Community based & Out-Reached Services
Inadequate skilled HR
Skills on Communication for behavior change
Community Behavior
Knowledge/ awareness , motivation & resources
Facility services
Irregular supplies, Maintenance of public facilities ,
Lack of HR / of appropriate skill mix at various levels
Inequity of service provision to poor
Financial Barriers, cost of facility based
Lack of awareness & knowledge on danger signs
Quality of care, adherence protocol
Facilitative supervision , monitoring & accountability
Bottlenecks of ANC in Rajanpur
Insufficient ANC providers
100%
Relative inaccessibility/
lack of planning of ANC
80%
60%
Low demand, low
continuity
40%
Lack of quality of ANC
20%
0%
COMMODITIES:
Proportion
Preventive primary
health centres with
no IFA stock-out
HUMAN RES:
Availability of
nurses, midwives
and LHW
ACCESS: Proportion
women with ANC
access
UTILISATION:
Proportion pregnant
women with ANC 1+
Baseline
CONTINUITY:
Proportion pregnant
women with ANC 4+
EFFECTIVE COV:
Proportion pregnant
women with ANC
4+, 1st trimester
Bottlenecks of Skilled delivery
before the 24/7
100%
80%
Absence of female SBA
60%
Financial barriers
40%
Lack of quality from ANC to SBA
20%
0%
COMMODITIES:
HUMAN RES:
Proportion of clinical
primary health centre Availability of nurses,
with no stock-outs of LHV, midwives, WMO
delivery kits
ACCESS: % women
having access to health
care
UTILISATION: % of
births assisted by a
skilled provider
Baseline
CONTINUITY: % live
births delivered by a
SBA in a health facility
EFFECTIVE COV: % live
births delivered by a
SBA in a health facility
& PNC within 24 hrs.
Bottlenecks of Early initiation of
Breastfeeding & temperature
management
Women delivering without
SBA, without proper care &
100%
counseling
Insufficient deployment &
80%
support of CMW
Lack of awareness and
60%
knowledge on essential
40%
newborn care & practices
20%
0%
COMMODITIES: %
HUMAN RES: %
mothers delivering
villages w CMidwives ACCESS: % mothers 1
at a facility
ANC or home visit
trained on skin to
skin & early
breastfeeding
UTILISATION: %
children on breast 1
hr after birth
Baseline
CONTINUITY: %
mothers practicing
skin to skin contact
in delivery room
EFFECTIVE COV: %
mothers practicing
Bf < 1hr + skin to skin
HOW? : Selecting Strategies
35%
30%
25%
To
Coverage
20%
15%
10%
From
inputs 35
5%
30
25
20
15
10
5
0
5% 10% 15% 20% 25% 30% 35%
10
102
Bottleneck
analysis then allows
10
formulation
of strategies to
10
improve
efficiencies within the
10
system
10
3
4
5
6
107
MNCH/ LHW programme strategy before 24/7
ANC
100%
80%
60%
• Recruitment and training
of
40%
20%
0%
B…
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
COMMODITIES: Proportion of clinical primary health centre with no
stock-outs of delivery kits
HU MAN RES: Availability of nurses, LHV, midwive s, WMO
ACCESS: % wome n having acces s to health care
UTILISATION : % of births assis te d by a skilled provider
CONTIN UITY: % live births delivered by a SBA in a he alth facility
EFFECTIVE COV: % live births delivered by a SBA in a health facility & PN C
within 24 hrs.
Baseline
50%
40%
30%
20%
10%
0%
COMMODITIES: %
mothers delivering at a HUMAN RES: % villages w
facility
CMidwives trained on
skin to skin & early
breastfeeding
ACCESS: % mothers 1
ANC or home visit
UTILISATION: % children
on breast 1 hr after birth
CONTINUITY: % mothers
practicing skin to skin
contact in delivery room
Baseline
EFFECTIVE COV: %
mothers practicing Bf <
1hr + skin to skin
– LHW on ANC, on
Community newborn, on
referral for SBA, on PNC
– CMW on ANC, on
Community newborn, on
performing SBA and
referring complications,
• Unclear referral pathway,
• Uncovered area
• Skill gaps and Quality of
care
MNCH/ LHW programme strategy WITH 24/7
•
100%
–
–
80%
60%
•
•
40%
0%
B…
–
–
100%
–
80%
–
–
60%
40%
•
20%
COMMODITIES: Proportion of clinical
primary health centre with no stockouts of delivery kits
HUMAN RES: Availability of nurses,
LHV, midwives, WMO
ACCESS: % women having access to
health care
UTILISATION: % of births assisted by a
skilled provider
CONTINUITY: % live births delivered
by a SBA in a health facility
EFFECTIVE COV: % live births delivered
by a SBA in a health facility & PNC
within 24 hrs.
80%
–
•
•
60%
40%
Equity focused
0%
COMMODITIES: %
HUMAN RES: %
mothers delivering at a
villages w CMidwives
facility
trained on skin to skin
& early breastfeeding
ACCESS: % mothers 1
ANC or home visit
UTILISATION: %
children on breast 1 hr
after birth
CONTINUITY: %
mothers practicing
skin to skin contact in
delivery room
Baseline
EFFECTIVE COV: %
mothers practicing Bf
< 1hr + skin to skin
Pay for performance
Rs. 500 will be paid to the LHV/midwife for
institutional deliveries conducted from 3 pm to
8 am (Evening & night shifts)
Reporting & Monitoring System.
Still lack of HR 24/ 7 in some remote locations
Stock replenishment to follow increasing
demand
–
20%
Renovation of health facilities
Provision of Ambulance at some of the
selected HFs
Call Response Center
Pickup of women in labor from her home to
the BHU
Transfer of complicated cases to nearest
Comprehensive EmONC facility
Linkages with Teaching Hospitals
Security
Quality:
–
–
Equity focused
Current
Baseline
Provision of Equipment
Generators/ UPS
Additional HR---Technical & non technical
Access:
–
–
20%
0%
Availability:
Stock out of contraceptives, essential supplies
(drugs)
Reality check:
BHU Progress (Overall 7 Districts)
Deliveries
Antenatal Care
23
200
156
119
19
16
143
133
20
19
25
1
Baseline December January February
March
Target
Baseline December January February
Post Natal Care
23
Target
Family Planning Cases
27
40
27
March
26
23
31
20
15
15
3
2
Baseline December January February
March
Target
Baseline December January February
March
Target
Designed an Equity-focused approach
1. Scaling Up integrated high impact intervention package
2. Ensuring Universal Geographic Access:
•
•
•
Shifting treatment of main child killers to communities
Providing maternal and newborn services closer to communities
Incentives for improved distribution and performance of health workers
3. Reducing financial barriers for the poor
•
•
•
Reducing costs of drugs and other commodities
Insurance or free provision of services for the poor
Subsidizing indirect costs for using services e.g. through cash transfers
4. Increasing demand by empowering communities
•
•
•
Community participation and organization
Community based promotion of positive health-nutrition related practices
Intensified communication e.g face to face
5. Quality assurance
•
through training, supervision, monitoring and accreditation
Sustaining and scaling up with equity 24/7
•
ANC
100%
–
•
80%
40%
•
20%
HUMAN RES: Availability of nurses,
midwives and LHW
Current
ACCESS: Proportion women with ANC
access
Baseline
UTILISATION: Proportion pregnant
women with ANC 1+
CONTINUITY: Proportion pregnant
women with ANC 4+
–
EFFECTIVE COV: Proportion pregnant
women with ANC 4+, 1st trimester
100%
•
80%
60%
•
Comprehensive
0%
Equity focused
COMMODITIES: Proportion of clinical primary health centre with no
stock-outs of delivery kits
Current
HU MAN RES: Availability of nurses, LHV, midwive s, WMO
ACCESS: % wome n having acces s to health care
UTILISATION : % of births assis te d by a skilled provider
100%
Baseline
CONTIN UITY: % live births delivered by a SBA in a he alth facility
EFFECTIVE COV: % live births delivered by a SBA in a health facility &
PN C within 24 hrs.
80%
60%
40%
20%
0%
Equity focused
COMMODITIES: % mothers
delivering at a facility
HUMAN RES: % villages w
CMidwives trained on skin to ACCESS: % mothers 1 ANC or
skin & early breastfeeding
home visit
UTILISATION: % children on
breast 1 hr after birth
CONTINUITY: % mothers
practicing skin to skin
contact in delivery room
Baseline
EFFECTIVE COV: % mothers
practicing Bf < 1hr + skin to
skin
•
•
Security, Gender balance (female providers)
more intensive communication & behaviour change
interventions
Quality:
–
–
20%
Vouchers scheme, Conditional cash transfer
Public private partnership (taxis)
Utilisation
–
40%
Free transportation, Up to tertiary level of care
•
•
Equity focused
COMMODITIES: Proportion
Preventive primary health centres
with no IFA stock-out
Clarify roles of CMW and LHW throughout the
continuum of care- esp. community
Access:
–
Comprehensive
Provision of newborn kit to CMW and LHW
Additional HR and task shifting
–
60%
0%
Availability:
Pay for performance
Supportive supervision
Greater priority to delivery to the most deprived
Change of behavior/ Social habits
–
–
–
–
–
Health seeking
Reproductivehealth
Family planning and birth spacing
Early marriage and early pregnancy
Newborn feeding and care/ practices
Polio eradication:
Equity approach and routine EPI
100%
80%
60%
40%
20%
Comprehensive
Equity focused
0%
COMMODITIES:
EDO without HUMAN RES:
UC with
stock out
Vaccinators
Current
ACCESS: % UC
UTILISATION: %
adequately
infants
covered by
vaccinated
for
fixed centers &
Penta
1
outreach teams
Baseline
CONTINUITY: %
infants
vaccinated for
Penta 3
EFFECTIVE COV:
% infants fully
immunized
Modeling Impacts, Costs and Cost-Effectiveness of strategies
Coverage
Health Output: MDGs Outcome
Examples of Inputs
Determinants Increase coverage
interventions
Warehouses; trucks;
management systems
Pre-service training;
inputs for a mobile team,
construction of health post
, hardship allowances
Consumables, subsidies
for insurance,
communication
Demand side subsidy,
performance-based
incentives communication.
Availability
Commodities
Availability of
HR
Access to
Infrastructure
Utilization
Adequate
Coverage
Effective
Training,
supervision
monitoring etc.
Coverage
Family/community
preventive &
curative
WASH, health &
nutrition
Population oriented
schedulable,
preventive health,
HIV AIDS & nutrition
Individually oriented
non schedulable
curative
health & nutrition
interventions
Aggregate cost of inputs
Impact on
MDG
1c,4,5,6,7c
indicators
Reduction
in burden of
deaths and
stunting
Cost Effectivenes
Cost of
removing
bottlenecks
to achieve
certain
MDG target
Equity: The Lancet equity series–
Latest Update
 June- Sept. : Narrowing
the Gap: SA contribution:
Feeding HQ….
• Bangladesh, Pakistan
ROSA Increased support to Bangladesh
• Equity data mapping: Nepal, Un. of Queensland
and Pakistan, deepening data,
• Review of literature: Un. of Queensland
improving
capacity/
buy in in country..
• Equity deprivation
score:
Sri Lanka
Delay in
supporting Sri Lanka Oct.- Nov.: Revisiting
Outline,
for completion
• Beijing RMT:ready
repositioning
regional since
papers,November
South Asia
Delay
Nepal and India:
 Dec.: Additional
data in
collection:
• 35 districts ofworking
Punjab, with
64 Bangladesh
districts
partners…….
 Jan. - March : PAKISTAN
In depth Revision
of MBB
leading:
Stronger knowledge
 Efficacy
& size
state of the art
• Costing:
OOPsto support
capacity
 Apr.: Final writing
of series
ready
for Bhutan, Afghanistan, Maldives?
UNICEF
What impact?
35%
30%
From
Coverage
25%
20%
15%
10%
5%
35
30
25
20
15
10
5
0
10
102
103
104
105
106
107
5% 10% 15% 20% 25% 30% 35%
To
Impact
Impact on reaching MDG 4 & 5
700
160
MDG 5
MDG 4
140
600
120
500
100
400
80
300
60
200
40
100
20
-
-
1980
1990
2000
2010
2020
1980
1990
2000
2010
2020
UNICEF
Past & current path
Equity focus
MDGs Goal
Estimating the number of lives saved
35%
and stunting avoided
30%
25%
20%
15%
10%
5%
35
30
25
20
15
10
5
0
5% 10% 15% 20% 25% 30% 35%
10
102
103
104
105
106
107
To Lives
Saved
From
Impact
Cost effectiveness: deaths& Stunting averted
per $ million averted
Stunting cases 12-23 Mo. averted
in 2015 per US$1 million
investment
Under 5 deaths averted in 2015
per US$1 million investment
180
800
160
700
140
600
120
500
100
400
80
300
60
200
40
20
100
0
0
Most Deprived
UNICEF
Medium
Deprived
Least
Deprived
Current Path
Most Deprived
Medium
Deprived
Least Deprived
Equity
From
Coverage
35%
30%
25%
20%
15%
10%
To
Cost
5%
35
30
25
20
15
10
5
0
5% 10% 15% 20% 25% 30% 35%
10
102
103
104
105
106
How much: costing10 and budgeting the
strategy
7
Preventing OOP of the poor
70%
60%
% out of pocket expected without
subsidies
50%
40%
30%
20%
% out of pocket in
(2015)
10%
0%
CURRENT
PATH
EQUITY
FOCUS
Most Deprived
UNICEF
CURRENT
PATH
EQUITY
FOCUS
Medium Deprived
CURRENT
PATH
EQUITY
FOCUS
Least Deprived
CURRENT
PATH
EQUITY
FOCUS
South Asia
Conceptual Framework for the interactions between
determinants of cost effectiveness and MDG impact
Increased
35%
Coverage
30%
Strategies to
remove bottlenecks of poor
Pro poor Service
Delivery Modes
Expenditure
35
30
25
20
15
10 5
(family/total)
more deaths +
stunting
prevented per
$ 1 m. in poor
than in rich
25%
20%
15%
10%
5%
0
10
102
103
104
Intervention packages
addressing causes of
death in the poor
Equity of
Outcomes
5% 10% 15% 20% 25% 30% 35%
Identify + focus
poor areas with
high # of births,
deaths, stunting
105
106
107
National
MDG Impact
Decentralized planning & management of implementation at
In CO that implemented relevant equity focused approach at scale RO & HQ
scale of intervention
packages and strategies to Reduce
support
Bottlenecks & Barriers in deprived areas/groups
Conclusion
• An equity-focused approach improves returns on
investment, averting many more child and maternal deaths
and episodes of stunting than the current path.
• Using an equity focused approach, a US $1 million
investment in reducing under-five deaths in a low-income,
high-mortality country would avert an estimated 60% more
deaths than the current approach.
• Because national burdens of disease, ill health and
malnutrition are concentrated in the most excluded and
deprived child populations, providing these children with
essential services can accelerate progress towards the
health related MDGs and reduce disparities within nations.
ROSA Investment case workplan to
respond to CO request- 2011
•
•
•
Request: > 60 Potential districts applications
Inter sectorial move: education/ protection
Networking of facilitators
•
•
•
Documentation
•
•
•
Inside UNICEF- capacity building on results based approach
Outside Pool of regional resources
•
Consultants: Public health financing
•
Institutions (University in South Asia and outside)
Lancet series
National publications
Capacity building in countries----Pakistan leading
•
•
Training materials adapted to South Asia
E-learning
•
Webinar: once monthly?
UNICEF
•
IC tool kit??? USE??
Challenges of Equity
approach in Pakistan in 2011
• Timely respond to Provinical Government
agenda- 18th amendment
• Linkages and results on key priorities
•
•
•
•
POLIO ERADICATION
Maternal and newborn mortality
Nutrition
Neglected Diarrhea and pneumonia
• TARGETING & IMPLEMENTING AMONG
THE MOST DEPRIVED for GREATER
RESULTS IN PAKISTAN